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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 371881400
Report Date: 03/27/2024
Date Signed: 03/27/2024 04:04:54 PM

Document Has Been Signed on 03/27/2024 04:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:FELICITA CAREFACILITY NUMBER:
371881400
ADMINISTRATOR:ROKSANDIC, DRAGANFACILITY TYPE:
735
ADDRESS:1661 ENCINO DRIVETELEPHONE:
(310) 994-3990
CITY:ESCONDIDOSTATE: CAZIP CODE:
92025
CAPACITY: 6CENSUS: 0DATE:
03/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dragan Roksandic, AdministratorTIME COMPLETED:
04:05 PM
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On 3/20/2024, Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an attempted visit to conduct an annual inspection. LPA rang the doorbell three times and no one answered. LPA observed there were no cars in the driveway. LPA contacted Administrator and Administrator stated they were unable to meet today.

On 3/27/2024, Licensing Program Analyst (LPA) Jacqueline Shaw Ross made an unannounced visit to the facility to conduct an annual licensing inspection. LPA was met by Dragan Roksandic, Administrator, and explained the purpose of the visit. Mr. Roksandic informed LPA the facility does not have any residents yet. The facility is a one story, six bedroom and three bathroom home. The facility is licensed to serve six adult ambulatory residents of which one may be non-ambulatory.

A tour of the facility was conducted inside and out. LPA, accompanied by Mr. Roksandic, conducted a general overall inspection. LPA observed the following: Indoor and outdoor passageways were observed to be free from obstruction. There are no pools or bodies of water. Per Administrator, there are no firearms or other dangerous weapons in the facility. Poisons and cleaning agents were observed to be secured and inaccessible. Facility fire clearance is maintained in conformity with State Fire Marshal regulations. LPA toured every room in the facility. Rooms designated as resident rooms had the required furnishings and sufficient lighting available. LPA observed linen, in good repair, and sufficient hygiene products for personal use. The hot water temperature measured 135 degrees but was lowered to an appropriate range. The facility had a functioning carbon monoxide detector, multiple smoke detectors, and two operable fire extinguishers. The facility was stocked with a two-day supply of perishable food items and a seven-day supply of nonperishable food items. The facility also has emergency food and water available.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: FELICITA CARE
FACILITY NUMBER: 371881400
VISIT DATE: 03/27/2024
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There are no staff records nor resident records at the moment until the facility obtains clients. There are also no medications to review, however, LPA observed where medications will be stored.

No deficiencies were observed during today's visit. An exit interview was conducted and a copy of this report was provided at the conclusion of the visit.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Jacqueline Shaw Ross
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
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